2. DECEASED INFORMATION
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Veteran*
    -- Select One --YesNo
16. Marital Status
    -- Select One --MarriedSingleDivorcedWidow/Widower
17. Date of Birth*
    Date of Birth
18. Date of Death*
    Date of Death
20. Next of Kin First Name*
21. Next of Kin Last Name*
23. Relationship*
    -- Select One --Mother/FatherSon/DaughterSpouseBrother/SisterOther
24. Type Relationship if other
25. Next of Kin Phone No.
29. BURIAL INFORMATION
31. Burial Day*
32. Burial Date*
    Burial Date
33. Burial Time*
35. Burial Space Ownership*
    -- Select One --At NeedPre-need

    If the deceased owns a plot at the Hallandale Beach Cemetery it is a pre-need. If not, it is at-need.
36. Owner's Name and Space Number
38. Burial Type

    1. Single
    2. Double
    3. Baby
    4. Niche
    5. Oversized
39. Burial Fee Weekday (At Need)
    -- Select One --$2,880.44 Res NVet Sgl Spc$3,039.87 Res NVet Ovrzd Spc$2,618.44 Res Vet Sgl Spc$2,777.87 Res Vet Ovrzd Spc$4,418.44 NRes NVet Sgl Spc$4,557.87 NRes NVet Ovrzd Spc$3,964.44 NRes Vet Sgl Spc$4,124.07 NRes Vet Ovrzd Spc$604.10 Infant$1,118.10 Cremation Niche
40. Burial Fee Weekend (At Need)
    -- Select One --$3,461.44 Res NVet Sgl Spc$3,620.87 Res NVet Ovrzd$3,199.44 Res Vet Sgl$3,358.87 Res Vet Ovrzd$5,428.44 NRes NVet Sgl$5,587.87 NRes NVet Ovrzd$4,974.64 NRes Vet Sgl$5,134.07 NRes Vet Ovrzd$1,185.10 Infant$1,118.10 Cremation NicheOther
42. Burial Fee Weeday (Pre Need)
    -- Select One --$1,488.44 Res Vet/NVet Sgl No Vault$1,647.87 Res Vet/NVet Ovrzd No Vault$994.10 Res Vet/NVet Sgl/Ovrzd Vault$1,998.44 NRes Vet/NVet Sgl No Vault$2,157.87 NRes Vet/NVet Ovrzd No Vault$1,504.10 NRes Vet/NVet Sgl/Ovrzd Vault
43. Burial Fees Weekend (Pre-Need)
    -- Select One --$2,069.44 Res Vet/NVet Sgl No Vault$2,228.87 Res Vet/NVet Ovrzd No Vault$1,575.10 Res Vet/NVet Sgl/Ovrzd Vault$3,008.44 NRes Vet/NVet Sgl No Vault$3,167.87 NRes Vet/NVet Ovrzd No Vault$ 2,514.10 NRes Vet/NVet Sgl/Ovrzd Vault
47. Funeral Home Name*
48. Contact Person Name*
50. Phone Number*
51. Email Address*
55. Back-up Documents Needed (Please Check Document Uploaded)

    1. Burial Transit Permit (Required Before burial can be scheduled)
    2. Proof of Residency in the City of Hallandale Beach (Driver's License, Utilitie Bill)
    3. Proof of Veteran Status
    4. Cemetery Plot Deed (for Pre-Need)
    5. Permission to Bury (for Pre-Need)
57. Burial Transit Permit
58. Proof of Residency
59. Proof of Veteran Status
61. Cemetery Plot Deed
62. Permission to Bury
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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